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VA Form 10-10EZR is used by VA to update your personal, insurance, or financial information after you are enrolled.
Where can I get help filling out the form and if I have questions? This update form is available for
completion online at www.va.gov/healthbenefits.
You may use ANY of the following to request assistance:
Ask VA to help you fill out the form by calling us at 1-877-222-VETS (8387).
Contact the Enrollment Coordinator at your local VA health care facility.
Contact a National or State Veterans Service Organization.
SERVICE-CONNECTED (SC): A VA determination that an illness or injury was incurred or aggravated in the line of duty, in the
active military, naval or air service.
COMPENSABLE: A VA determination that a service-connected disability is severe enough to warrant monetary compensation.
NONCOMPENSABLE: A VA determination that a service-connected disability is not severe enough to warrant monetary
compensation.
NONSERVICE-CONNECTED (NSC): A Veteran who does not have a VA determined service-related condition.
SPOUSE: If you are certifying that a person is your spouse for the purpose of VA benefits, your marriage must be recognized by the
place where you and/or your spouse resided at the time of marriage, or where you and/or your spouse reside when you file your claim
(or at a later date when you become eligible for benefits) (38 U.S.C. 103(c)). Additional guidance on when VA recognizes
marriages is available at http://www.va.gov/opa/marriage/.
financial information through a computer-matching program. You may count your spouse as your dependent even if you did not
live together, as long as you contributed support last calendar year. You may count your biological children, adopted children, and
stepchildren as dependents. These children must be unmarried and under the age of 18, or be at least 18 but under 23 and attending
high school, college or vocational school on a full or part-time basis, or have become permanently unable to support themselves
before reaching the age of 18.
VA FORM
MAR 2015
10-10EZR
Complete only the sections that apply to you; sign and date the form.
Continued ...
Section IV - Previous Calendar Year Gross Annual Income of Veteran, Spouse and Dependent Children.
Report:
Gross annual income from employment, except for income from your farm, ranch, property or business. Include your wages,
bonuses, tips, severance pay and other accrued benefits and your child's income information if it could have been used to pay
your household expenses.
Net income from your farm, ranch, property, or business.
Other income amounts, including retirement and pension income, Social Security Retirement and Social Security Disability
income, compensation benefits such as VA disability, unemployment, Workers Compensation and Black Lung, cash gifts,
interest and dividends, including tax exempt earnings and distributions from Individual Retirement Accounts (IRAs) or
annuities.
Do Not Report:
Donations from public or private relief, welfare or charitable organizations; Supplemental Security Income (SSI) and need-based
payments from a government agency; profit from the occasional sale of property; income tax refunds, reinvested interest on
Individual Retirement Accounts (IRAs); scholarships and grants for school attendance; disaster relief payments; reimbursement
for casualty loss; loans; Radiation Compensation Exposure Act payments; Agent Orange settlement payments; Alaska Native
Claims Settlement Acts Income, payments to foster parent; amounts in joint accounts in banks and similar institutions acquired by
reason of death of the other joint owner; Japanese ancestry restitution under Public Law 100-383; cash surrender value of life
insurance; lump-sum proceeds of life insurance policy on a Veteran; and payments received under the Medicare transitional
assistance program.
Report non-reimbursed medical expenses paid by you or your spouse. Include expenses for medical and dental care, medications,
eyeglasses, Medicare, medical insurance premiums and other health care expenses paid by you for dependents and persons for whom
you have a legal or moral obligation to support. Do not list expenses if you expect to receive reimbursement from insurance or other
sources. Report last illness and burial expenses, e.g., prepaid burial, paid by the Veteran for spouse or dependent(s).
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals
who must complete this form will average 15 minutes. This includes the time it will take to read instructions, gather the necessary facts
and fill out the form.
Privacy Act Information: VA is asking you to provide the information on this form under 38 U.S.C. Sections 1710, 1712, and 1722 in
order for VA to determine your eligibility for medical benefits. Information you supply may be verified from initial submission forward
through a computer matching program. VA may disclose the information that you put on the form as permitted by law. VA may make a
"routine use" disclosure of the information as outlined in the Privacy Act systems of records notices and in accordance with the Notice of
Privacy Practices. Providing the requested information is voluntary, but if any or all of the requested information is not provided, it may
delay or result in denial of your request for health care benefits. Failure to furnish the information will not have any effect on any other
benefits to which you may be entitled. If you provide VA your Social Security Number, VA will use it to administer your VA benefits.
VA may also use this information to identify veterans and persons claiming or receiving VA benefits and their records, and for other
purposes authorized or required by law.
VA FORM
MAR 2015
10-10EZR
Federal law provides criminal penalties, including a fine and/or imprisonment, for any materially false, fictitious, or
fraudulent statement or representation. (See 18 U.S.C. 287 and 1001).
1. VETERAN'S NAME (Last, First, Middle Name)
3. GENDER
MALE
FEMALE
8. CITY
11. COUNTY
9. STATE
MARRIED
NEVER MARRIED
SEPARATED
WIDOWED
DIVORCED
3. POLICY NUMBER
4. GROUP CODE
YES
NO
SECTION III - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
1. SPOUSE'S NAME (Last, First, Middle Name)
11. WAS CHILD PERMANENTLY AND TOTALLY DISABLED BEFORE THE AGE OF 18?
SON
YES
DAUGHTER
STEPSON
STEPDAUGHTER
NO
NO
13. EXPENSES PAID BY YOU FOR YOUR DEPENDENT CHILD FOR COLLEGE,
VOCATIONAL REHABILITATION OR TRAINING (e.g., tuition, books, materials)
14. IF YOUR SPOUSE OR DEPENDENT CHILD DID NOT LIVE WITH YOU LAST
YEAR, DID YOU PROVIDE SUPPORT?
YES
NO
VA FORM
MAR 2015
10-10EZR
PAGE 1
SECTION IV - PREVIOUS CALENDAR YEAR GROSS ANNUAL INCOME OF VETERAN, SPOUSE AND DEPENDENT CHILDREN
(Use a separate sheet for additional dependents)
VETERAN
SPOUSE
CHILD 1
2. AMOUNT YOU PAID LAST CALENDAR YEAR FOR FUNERAL AND BURIAL EXPENSES (INCLUDING PREPAID BURIAL EXPENSES) FOR
YOUR DECEASED SPOUSE OR DEPENDENT CHILD (Also enter spouse or child's information in Section III.)
3. AMOUNT YOU PAID LAST CALENDAR YEAR FOR YOUR COLLEGE OR VOCATIONAL EDUCATIONAL EXPENSES (e.g., tuition, books, fees,
materials) DO NOT LIST YOUR DEPENDENTS' EDUCATIONAL EXPENSES.
SIGNATURE OF APPLICANT
VA FORM
MAR 2015
10-10EZR
DATE
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